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Acute epiglottitis is an airway emergency presenting with edema and inflammation of the epiglottis and aryepiglottic folds [1]. Infectious and other non-infectious etiologies may cause significant airway injury presenting with similar clinical symptoms and radiographic findings [1]. While many causes of thermal epiglottitis have been described in the pediatric and young adult population, we describe an unusual case of an adolescent patient with cannabis induced thermal epiglottitis. A 17-year-old previously healthy, vaccinated adolescent male presented to the pediatric emergency department with dysphagia, odynophagia, drooling, and muffled voice with fever, tachypnea, and leukocytosis. Lateral plain film imaging and computed tomography (CT) scan showed significant edema of the epiglottitis. Urinary drug screen in the emergency department was positive for benzodiazepine, opiates, and cannabinoids. Transnasal flexible laryngoscopy and direct laryngoscopy demonstrated significant erythema, edema, and copious secretions. Culture of the epiglottis culture showed normal oropharyngeal flora. The patient was diagnosed with thermal induced epiglottitis secondary to cannabinoid use based on positive substance use history, urinary drug screen, and negative bacterial cultures. Clinicians must consider thermal injury of the epiglottitis due to substance use, specifically marijuana in vaccinated adolescent patients presenting with positive substance use history, progressive dysphagia, odynophagia, and drooling with a muffled voice. It is essential to obtain a thorough history and physical examination and urinary drug screen in the pediatric emergency department since the clinical and radiographic findings are similar in epiglottitis due to infectious and non-infectious etiologies. Prompt management with intubation should occur to protect and maintain airway integrity.

Human Papillomavirus (HPV) has been identified as an important risk factor that predisposes to cervical cancer. Traditionally the Papanicolaou (Pap) smear test has been routinely used for the detection of premalignant lesions in the uterine cervix. However, due to the rise in false positive and negative results, advanced molecular techniques like PCR are more sensitive and reliable. This study aimed to assess the burden of HPV infection in women with normal and abnormal Pap testing attending a tertiary care hospital. Methods A total of 126 sexually active women were recruited for cervical examination in this cross sectional study. Cervical exfoliated cells were collected for cytology and HPV analysis. DNA was extracted and HPV detection was performed using nested PCR technique. Results HPV prevalence was higher in women with abnormal cytology infection (12.5%) compared with those who had normal Pap smear(3.8%); HPV 16 was found to be the most common subtype. Younger age at marriage, multiple sexual partners, and multiparity were found to be the most important confounding factors in the acquisition of HPV. Conclusion The current study demonstrated the presence of high-risk HPV in cervical smear specimens irrespective of normal and abnormal cytology, and hence emphasizes the need for implementation of effective national cervical cancer screening programs that could decrease the burden of cervical cancer in India.

Objective: Safe and effective human papillomavirus vaccines are available against cervical cancer and other human papillomavirus–associated diseases. Vaccine uptake is low in India given lack of universal vaccination programme. This exploratory study describes the medical, dental and nursing undergraduate student perspectives about human papillomavirus and intentions to receive the vaccine. Methods: Using a cross-sectional, explorative study design, we conducted two focus group discussions among a convenience sample of male (n = 11) and female (n = 9) student group aged ⩾18 years, respectively, at a medical college in South India. The focus group discussion sessions were recorded, transcribed and analysed using thematic content analysis. Results: Over half of the students showed adequate knowledge of cervical cancer and human papillomavirus. Medical students had much in-depth knowledge of cervical cancer, vaccine cost and its side effects compared to dental and nursing students. Human papillomavirus vaccine knowledge was relatively less among males compared to females; most male participants were unaware of the availability of the human papillomavirus vaccine. Intention to receive the vaccine was higher among females than males. All the participants had positive attitude in creating awareness in the community and making the vaccine cost-effective. Cultural concerns and high vaccine cost were cited major barriers for vaccine uptake. Suggestion of physician recommendation in promotion of human papillomavirus vaccine uptake was an emerging theme. Conclusion: Educating male students and those enrolled in dental and nursing courses about human papillomavirus vaccine, addressing cultural concerns and advocating provider recommendation for promoting vaccine uptake are potential strategies to improve future human papillomavirus vaccine intent among students and recommendations to patients in their role as future healthcare provider.

Cervical cancer is the second leading cause of cancer and one of the leading causes of cancer-related death in women in India. Human papillomavirus (HPV) vaccine uptake in India is low due to cost, low awareness of HPV, social stigma, and other factors. We assessed the awareness, attitudes, and beliefs regarding HPV and HPV vaccination and explored the barriers and challenges to HPV vaccine intent among women in Mangalore, India. An exploratory study was conducted using two focus group discussions (FGDs) and six in-depth one-on-one interviews. FGD-1 comprised nine women aged 18 to 26 years, and FGD-2 comprised seven women aged 27 to 45 years. The FGDs were recorded, transcribed, and analyzed using thematic content analysis. Themes identified were limited knowledge of HPV and vaccine, stigma associated with receiving HPV vaccine, vaccine safety concerns, and cost as a barrier to receiving vaccine. Participants expressed desire for physician and government recommendation of the HPV vaccine to validate vaccine intent. Contrasting themes between the two FGDs include support for vaccination at a younger age and lower perception of stigma and judgment in the 18- to 26-year-old group; however, participants in the 27- to 45-year-old group support vaccination at an older age and endorse greater fear of stigma and judgment associated with obtaining vaccination. Education regarding HPV-associated diseases and the HPV vaccine for the general public, physicians, and government officials in conjunction with lowering vaccine cost, improving vaccine access, and encouraging strong physician recommendations are key strategies to scale up HPV vaccine implementation in India.

This case highlights the need for accurate and rapid testing for SARS-CoV-2 and also underscores the need for caregivers to remain vigilant for COVID-19 in the post-operative setting despite negative pre-operative testing.

A previously healthy 15-year-old boy from a rural county in the southeastern United States was evaluated in the emergency department with fever and worsening toe pain in the absence of trauma. He initially presented to his primary care physician 4 weeks before with upper respiratory symptoms and was treated with corticosteroids for presumed reactive airway disease. His respiratory symptoms resolved. One week after this presentation, he developed fever and right great toe pain and presented to an outside hospital. Inflammatory markers were elevated. MRI confirmed a diagnosis of osteomyelitis with associated periosteal abscess. He was treated with intravenous antibiotics and drainage of the abscess. Ten days after his discharge from the outside hospital, he developed fever and had increasing drainage of the toe and pain refractory to oral pain medications. He presented to our facility for further evaluation. Repeat MRI and inflammatory markers corroborated his worsening disease, and he was admitted to the hospital for intravenous antibiotics and underwent serial surgical debridement. He developed painful subcutaneous nodules on his lower extremities and was found to have lung abnormalities on chest radiograph. A multispecialty team collaborated in the management of this patient and unveiled a surprising diagnosis.

The caregivers of HIV-positive children either delay or avoid disclosure of HIV status to the child due to several reasons. Keeping the child's HIV status a secret puts them at considerable risk of stopping therapy and transmitting HIV to others. Hence this study was conducted to assess the determinants of disclosure of HIV status to infected children in coastal Karnataka. A cross-sectional study was conducted in a District Hospital in Coastal Karnataka from October 2014 to July 2015. One hundred eighty-five caregivers were recruited for the study purposively and interviewed using a pre-tested, semi-structured questionnaire after written informed consent. Of the 185 caregivers interviewed, 78 (42%) caregivers had not disclosed the HIV status to the child. The child being too young was the most common reason for non-disclosure of HIV status. The majority of the caregivers intended to disclose the HIV status fully to the child after the child attained ten years of age. Nearly two-thirds of the caregivers wanted to disclose it themselves in their own homes. The significant determinants of disclosure of HIV status were the age of the child, and person involved in childcare, and the venue of the disclosure.

Background: Children with disabilities are expected to have poor nutritional status in comparison to children without disabilities. However, limited data on nutritional status of children with and without disabilities in rural settings in India. Objective: To assess and compare the nutritional status of children with and without disability. Methods: A cross-sectional study among children aged 5–15 years was conducted in the rural practise area of a medical college in Karnataka. 290 children (145 with and 145 children without disability) of similar age and sex were studied. Age and sex-specific World Health Organization (WHO) BMI centiles, 24 h dietary calorie and protein intakes were assessed and compared. Median and interquartile ranges were calculated for quantitative variables. Mann–Whitney U test was used to assess the differences in quantitative variables among the two groups. Results: As per WHO BMI centiles, 33.1% with and 37.20% without disabilities were undernourished. The median calorie consumed by children with disabilities was 1169.0 (946.5–1586.0) significantly lower compared to that of children without disability, that is, 1362.0 (1167.0–1641.0). The median protein consumed by children with disabilities was 28.0 (22.5–38.0) significantly lower compared to that of children without disability, that is, 32.0 (28.0–40.0). Conclusions: Children with disabilities had similar rates of undernutrition as that of their non-disabled peers and their lesser dietary intake in terms of calories and proteins.

Introduction: Community Acquired Pneumonia (CAP) is associated with high morbidity and mortality worldwide. Knowledge of common microbial patterns in CAP is crucial for making initial therapeutic decisions for empiric antimicrobial treatment. Aim: To determine the bacterial aetiology of CAP among hospitalised patients in a tertiary care hospital of Southern India. Materials and Methods: A descriptive study was carried out among 220 adult subjects, enrolled from a period of August 2012 to August 2014, admitted to a tertiary care hospital of Southern India, with a provisional diagnosis of CAP. Subjects were recruited based on chest radiography and clinical criteria. Blood, sputum, pleural fluid, Bronchoalveolar Lavage (BAL) and tracheal aspirates were obtained for microbiological investigations. Antimicrobial susceptibility testing was carried out on Streptococcus pneumoniae and Staphylococcus aureus isolates. The clinical specimens were further subjected to Polymerase Chain Reaction (PCR) to confirm the bacterial aetiology of S.pneumoniae and Haemophilus influenzae. Study data were summarised by frequency and percentage using SPSS (Statistical Package for Social Sciences) version 16.0. Results: A total of 220 subjects who were diagnosed for CAP of which 154 (70%) were culture negative and 66 (30%) were culture positive cases of CAP. The most commonly isolated pathogens were 29 (44%) of S.pneumoniae followed by 21 (32%) of S.aureus, 10 (15%) of H.influenzae and 6 (9%) of Klebsiella pneumoniae. Resistance to penicillin occurred in 24 (82.75%) of S.pneumoniae isolates. Methicillin-Resistant Staphylococcus aureus (MRSA) was demonstrated among 10 (48%) of the 21 total S.aureus CAP cases. Conclusion: Culture-based aetiologic diagnosis of CAP was made in only one-third of the cases. Ongoing antimicrobial resistance surveillance to S.pneumoniae and S. aureus is recommended. Determining the resistance profile of Klebsiella pneumoniae and H.influenzae is needed as pneumonia caused due to Gram negative aetiology is rising in the community setting. Rapid screening of bacterial CAP pathogens from clinical samples using PCR may be beneficial for clinicians to make a prudent antibiotic choice for CAP.

Late presentation to healthcare by HIV infected patients’ is common in India despite access to free combination antiretroviral therapy (cART). We assessed risk factors for late presentation among patients with a recent HIV diagnosis in an academic university–based antiretroviral treatment center. This retrospective study included 474 recently diagnosed HIV-infected patients registered for cART between 2012 and 2013. Subjects with CD4(+) T-lymphocyte (CD4) count ≤ 350 cells/μL or with an AIDS defining event were defined as late presenters (LP) and patients with CD4 count ≤ 200 cells/μL or with an AIDS defining event were defined as LP with advanced HIV disease (LPAD). Multivariable logistic regression analysis was used to investigate factors associated with late presentation. Of the 474 patients, 356 (75.1%) were LP. Of these, 299 (83.99%) were LPAD and 57 (16.01%) LP were AIDS-free. Median CD4 count among LP was 134 cells/μL (interquartile range 72.25–219). Mean age of LP was 42.50 ± 8.88 years; 256 (71.9%) were males. Increasing age (> 51 years; Adjusted odds ratio [aOR] 4.19; P = 0.014) and rural residence (aOR 3.19; P = < 0.001) were independently associated with late presentation. HIV-positive housewives (aOR 0.34; P = 0.027), HIV-positive individuals with negative partners (aOR 0.48; P = 0.006), and partners with unknown HIV status (aOR 0.43; P = 0.007) were less likely to present late compared with positive partners of people living with HIV/AIDS (PLWHA). Most patients were LP despite free access to cART. Rural population and older PLWHA should be targeted while implementing HIV care. There is a need to strengthen the HIV care cascade by linking PLWHA to cART immediately after diagnosis.

Background Hemophagocytic lymphohistiocytosis (HLH) is an uncommon hyperinflammatory condition in children that may acutely mimic septic shock. Sudden out-of-hospital cardiac arrest in children is also uncommon and may be of unclear etiology upon initial presentation. Case Report A 10-year-old previously healthy child presented with sudden cardiac arrest after an insidious course of throat pain, fever, and progressive altered mental status. He was subsequently diagnosed with Epstein-Barr virus-associated HLH and suffered cerebral edema and death. Why Should an Emergency Physician be Aware of This? HLH has not previously been described as a cause of sudden out-of-hospital cardiac arrest in children. Rapid diagnosis of underlying cause of an unexpected cardiac arrest may help guide appropriate therapy to salvage organ function.

Aim To evaluate the local treatment-seeking behaviors of diabetics with a focus on the root causes of culture-specific barriers to treatment compliance and define targets for intervention. Methods A cross-sectional survey was administered in the local language to 204 diabetic adults in rural and urban clinical settings. Fasting blood glucose level was measured in all participants prior to the survey. Questions included sociodemographic characteristics, treatment-seeking behavior, and perceptions of obstacles. Results Out of 204 participants, predictors of at target status included age (OR 1.06, 95% CI 1.02–1.11) and rural living area (OR 1.92, 92% CI 1.02–3.60). Participants were commonly diagnosed with symptoms of diabetes (44.6%). Participants demonstrated frequent healthcare provider contact (51% in last one month, 74.5% in last three months). Accidental or purposeful deviation from the recommended medications or treatment plan was reported by 18.7% and 12.8%, respectively. From the sample, 111 participants (54.4%) were capable of receiving SMS messages and 79 (71.1%) were willing to receive messages about diabetes. The most frequently self-reported obstacles to diabetes management were: medication costs (49.3%), treatment costs (46.6%), diabetic diet (33.8%), lack of relief on current treatment (17.4%), and transportation (16.7%). Conclusion Though most diabetics have frequent encounters with healthcare providers and report compliant behaviors, the majority do not meet recommended diabetes management guidelines. Screening of at-risk populations, targeted SMS campaigns, or diabetes-specific training for healthcare providers may improve clinical outcomes.

Background: Antibiotic overuse is a major public health challenge worldwide. Data from India related to physician antibiotic prescribing patterns are limited. Aims: We assessed antibiotic prescribing knowledge, attitudes, and practices among physicians in Mangalore, South India. Materials and Methods: Using a cross-sectional descriptive study design, physicians at academic tertiary hospitals completed an anonymous on-site survey. The survey items incorporated Likert scales, and data were analyzed using SPSS version 15.0. Results: Of the 350 physicians approached using a convenient sampling method, 230 (66%) consented and interviewed. The physician's knowledge of resistance patterns of common bacteria was related to receiving periodic updates on resistance patterns of bacteria (P = 0.019) and participation in courses on antibiotics (P = 0.026). Individuals with more number of years of experience (mean of 11 years) were less likely to justify antibiotic use for uncomplicated bronchitis (P = 0.015) and acute gastroenteritis (P = 0.001). Most respondents (n = 204, 89%) believed that physicians overprescribed antibiotics in routine clinical practice. Forty-five percent (n = 104) stated that their hospitals did not have an infection control policy in place. Conclusions: This study provides some understanding of physician's antibiotic prescribing patterns from teaching hospitals in India. Judicious antimicrobial use through educational and antimicrobial stewardship programs remains critical to control the spread of antibiotic resistance.

In recent years, there has been a substantial increase in refugee and asylum-seeking adults, adolescents and children to high-income countries. Infectious diseases remain the most frequently identified medical diagnosis among U.S.-bound refugee children. Medical screening and immunization are key strategies to reduce the risk of infectious diseases in refugee, internationally adopted, and immigrant children. Notable infectious diseases affecting refugee and other newly arriving migrants include latent or active tuberculosis, human immunodeficiency virus type 1 (HIV), hepatitis B, hepatitis C, vaccine-preventable diseases, malaria, and other parasitic infections. The U.S. Centers for Disease Control and Prevention and the American Academy of Pediatrics have published guidelines for health assessment of newly arriving immigrant, refugee, and internationally adopted children. Although, data on the health risks and needs of refugee exists in some high-income countries, there is an urgent need to develop robust evidence-informed guidance on screening for infectious diseases and vaccination strategies on a broader scale to inform national policies. Innovative approaches to reach migrant communities in the host nations, address health and other complex barriers to improve access to high-quality integrated health services, and strong advocacy to mobilize resources to improve health, safety, and wellbeing for refugee children and their families are urgent priorities.

Background: The epidemiology of acute hematogenous osteomyelitis (AHO) in children has changed. Methods: We reviewed the current literature regarding the epidemiology, microbiology, pathogenesis, clinical presentation, diagnosis, and antimicrobial management of AHO in children. Results:Staphylococcus aureus is the most common microorganism causing pediatric AHO, followed by group A Streptococcus (GAS). AHO due to community-associated methicillin-resistant Staphylococcus aureus (MRSA) can cause severe and complicated disease. Pathogen isolation by culture is key for targeted antibiotic therapy. Polymerase chain reaction assay in tissue sample or joint fluid may enhance the yield of Kingella kingae. C-reactive protein is useful in diagnosis and monitoring the course of AHO. Magnetic resonance imaging is the preferred diagnostic imaging study for AHO. Clindamycin or vancomycin (for serious disease) is recommended for empiric therapy of suspected AHO due to MRSA depending on the geographic prevalence. Penicillinase-stable penicillins or first-generation cephalosporins are preferred antibiotics to treat methicillin-sensitive S aureus (MSSA) infection. Beta-lactam agents are the drugs of choice for treating AHO due to K kingae, GAS, or Streptococcus pneumoniae. For uncomplicated AHO due to MSSA, a short parenteral antibiotic course followed by oral therapy for a minimum total duration of 3-4 weeks is adequate. Complicated AHO due to MRSA may warrant prolonged therapy with surgical intervention. Conclusion: Given the evolution of pathogens, the variability in clinical presentations and course ranging from simple to complex disease, and response to treatment, the management of AHO continues to evolve and warrants an individualized, multidisciplinary approach.

Septic arthritis in children is a medical emergency, needing prompt diagnoses, drainage of the synovial space, and antimicrobial therapy to prevent poor outcomes. The most common mode of transmission is hematogenous dissemination to the synovial joint. Septic arthritis is most commonly seen in boys and mainly affects the weight-bearing joints. The most common bacteria are dependent on age, but across all age groups, Staphylococcus aureus is the most common. To appropriately diagnose and treat septic arthritis, a multidisciplinary approach with microbiology support, radiologists, pediatricians, rheumatologists, infectious disease specialists, and orthopedic surgeons is ideally needed. Septic arthritis in a child, especially of the hip, is a medical emergency and requires urgent orthopedic consultation for surgical drainage and joint space irrigation (Laine, J PediatrOrthop B24(2):95–98, 2015). Prompt initiation of empiric parenteral antibiotics at high doses against Staphylococcus aureus is needed in all age groups. Empiric intravenous therapy against Kingella kingae is recommended in patients 3 months to 5 years of age, as it is becoming the predominant organism in this age group in some settings. A transition to oral therapy is made by clinical/laboratory/microbiological improvement with expected duration of therapy from 2 to 4 weeks. It is essential for patients to have close follow-up to prevent poor outcomes such as limb length discrepancy, hip dislocation, osteoarthritis, avascular necrosis of the femoral head, and ankylosis.

Acute appendicitis is a common disease afflicting the pediatric population. There are textbook presentations of periumbilical abdominal pain that migrates to the right lower quadrant with following nausea, possible diarrhea, anorexia, fever and eventual sepsis. The abnormal presentations are difficult to sort at times and varying presentations have been noted. The differential should remain broad in evaluating patients as our case illustrates. Keywords: Acute appendicitis, Amyand hernia, Scrotal abscess

Introduction: Malnutrition is a leading cause of childhood mortality and morbidity. It is a silent emergency which results from combination of factors and conditions. Growing children are most vulnerable to its consequences. Aim: To determine the prevalence of malnutrition among preschool children in Karnataka. Materials and Methods: A systematic review and meta-analysis was done to find out the pooled estimation of prevalence of malnutrition. An extensive literature search of International and National electronic databases were carried out. The criteria used for the search were limited to descriptive studies, cross- sectional studies, and epidemiological studies in English language. Out of 2183 studies, 28 papers were assessed for methodological quality and finally 24 papers were included in the review based on the inclusion and exclusion criteria. These studies were then subjected to quality of assessment using the STROBE guidelines. Results: Out of 24 articles, 19 articles were graded prevalence of malnutrition as per New WHO 2006 child growth standards and five studies were graded malnutrition as per IAP classification. The pooled prevalence of malnutrition as per IAP classification was 41% with 95% CI (0.23- 0.59). The pooled prevalence of underweight as per WHO child growth standard was 44% with 95% CI (0.38–0.49), stunting 35% with 95% CI (0.31-0.40), and wasting 28% with 95% CI (0.17–0.38). Conclusion: The findings of this review indicate that malnutrition is still an important problem in children. There is a need for finding the risk factors for malnutrition and a consistent effort from departments and parents concerned to improve the nutritional status further to reduce morbidity among children.

Fine needle aspiration cytology (FNAC) can be quite helpful in distinguishing malignancy from infection. Fungal elements may be detected using routine stains as in our case. The present case describes a 64-year-old male presented with chills and mild dyspnea on exertion after completing four cycles of chemotherapy for stage IIA adenocarcinoma of the lung. Use of special stains to enhance cytomorphological changes in conjunction with microbiology culture results is critical to identify the specific microorganism.

Objective. To investigate the associations between patient age, sociological factors, and the microbiology of pediatric neck infections. Methods. Retrospective chart review of children up to 5 years old who underwent surgical management of suppurative cervical lymphadenitis. Results. A total of 76 individuals met inclusion criteria; 93% of culture-positive infections were caused by Staphylococcus aureus in infants, compared with 59% in children between 13 months and 5 years of age ( P = .002). Of the S aureus isolates, 51% were methicillin-resistant S aureus (MRSA) and 49% were methicillin-sensitive S aureus. Methicillin resistance was associated with African American race ( P = .004); 67% of participants received empirical antibiotics prior to admission. Of these, 73% received antibiotics in the β-lactam class, and 25% received treatment with clindamycin. Conclusions. Incidence of MRSA is high in infants with cervical lymphadenitis who fail empirical antibiotic therapy and require surgical management. Empirical coverage for cervical lymphadenitis with β-lactam antibiotics may provide inadequate coverage for early infection in this population.

Cervical cancer is the leading cause of cancer-related mortality among women in India; however, participation in prevention and screening is low and the reasons for this are not well understood. In a cross-sectional survey in August 2008, 202 healthy women in Karnataka, India completed a questionnaire regarding knowledge, attitudes, and practices related to human papillomavirus (HPV) and cervical cancer. Factors associated with vaccination and Papanicolau (Pap) smear screening acceptance were explored. Thirty-six percent of women had heard of HPV while 15% had heard of cervical cancer. Five percent of women reported ever having a Pap smear, and 4% of women felt at risk of HPV infection. Forty-six percent of women were accepting of vaccination, but fewer (21%) were willing to have a Pap smear. Overall, knowledge related to HPV and cervical cancer topics was low. Women with negative attitudes toward HPV infection were 5.3 (95% confidence interval (CI) 2.8-10) times more likely to accept vaccination but were not significantly more likely to accept Pap smear (odds ratio 1.5, 95% CI 0.7-3.0). Cost and a low level of perceived risk were the most frequent factors cited as potential barriers. Improving awareness of HPV and cervical cancer through health care providers in addition to increasing access to vaccination and screening through government-sponsored programs may be feasible and effective methods to reduce cervical cancer burden in India.

In February 2016, the World Health Organization declared Zika virus (ZIKV) infection a public health emergency of international concern, given the precipitous spread of the virus across the Americas. Unlike arboviruses such as Chikungunya and Dengue, which have also recently emerged in the western hemisphere, ZIKV was identified in communities where concurrent neurologic conditions such as microcephaly and Guillain-Barre (GB) syndrome were occurring at alarming rates. Thus, investigations to systematically evaluate the link between ZIKV, congenital malformations (including microcephaly) and GB syndrome remain a top priority.

Background: The counselors’ form the backbone of HIV/AIDS control program, and for voluntary counseling and testing services to be effective counselors’ opinions are crucial. Purpose: To assess the perceptions of integrated counseling and testing center (ICTC) counselors with respect to the training received, problems faced in providing services, and job satisfaction. Methods: Qualitative methods such as 1 focus group discussion and 7 in-depth interviews were conducted among 14 counselors employed at 13 ICTCs in a costal district of south India. Results: The counselors identified the need for improving refresher training; job perception and satisfaction among counselors was found to be poor; issues such as shared confidentiality and targets for counseling were perceived to affect the ICTC services. Conclusion: The issues identified by counselors such as problems related to refresher training, targets set for counseling and testing, the pay scale and shared confidentiality should be addressed for better service delivery.

Background. With prolonged replication, attenuated polioviruses used in oral polio vaccine (OPV) can mutate into vaccine-derived poliovirus (VDPV) and cause poliomyelitis outbreaks. Individuals with primary humoral immunodeficiencies can become chronically infected with vaccine poliovirus, allowing it to mutate into immunodeficiency-associated VDPV (iVDPV). It is unclear if children perinatally infected with the human immunodeficiency virus (HIV), who have humoral as well as cellular immunodeficiencies, might be sources of iVDPV. Methods. We conducted a prospective study collecting stool and blood samples at multiple time points from Zimbabwean infants receiving OPV according to the national schedule. Nucleic acid extracted from stool was analyzed by real-time polymerase chain reaction for OPV serotypes. Results. We analyzed 825 stool samples: 285 samples from 92 HIV-infected children and 540 from 251 HIV-uninfected children. Poliovirus shedding was similar after 0–2 OPV doses but significantly higher in the HIVinfected versus uninfected children after ≥3 OPV doses, particularly within 42 days of an OPV dose, independent of seroconversion status. HIV infection was not associated with prolonged or persistent poliovirus shedding. HIV infection was associated with significantly lower polio seroconversion rates. Conclusions. HIV infection is associated with decreased mucosal and humoral immune responses to OPV but not the prolonged viral shedding required to form iVDPV.

In low and middle-income countries (LMIC), transmission of HIV during breastfeeding represents a major public health challenge. Several viral, maternal clinical, immunological and genetic factors, as well as maternal-infant host factors and type of infant feeding may influence the risk of breastfeeding transmission of HIV. The mechanisms of breast milk HIV transmission are poorly understood. For mothers who are healthy and do not need combination antiretroviral therapy for their own health, randomized controlled trials have proven that administration of extended maternal triple-drug antiretroviral (ARV) prophylaxis or extended infant ARV prophylaxis can significantly reduce the risk of HIV transmission during breastfeeding. Based on this evidence, the World Health Organization (WHO) published new guidance in 2010 on the use of ARVs for treating pregnant women, and preventing mother-to-child HIV transmission (PMTCT). Although, remarkable advances have occurred in prevention of postnatal transmission during breastfeeding using antiretroviral strategies, a number of challenges remain. Future research must focus on field studies to evaluate programmatic implementation of new WHO PMTCT regimens, monitor long-term safety of ART exposure during pregnancy and lactation, and study emergence of ARV resistance (in mothers and infected infants despite prophylaxis).

Previously, the treatment of Staphylococcus aureus infections was less complex, as most of those isolated were susceptible to β-lactam antibiotics. In recent years, there has been a marked increase in the incidence of invasive community-acquired (CA) methicillin-resistant S. aureus (MRSA) among children worldwide. However, data on the clinical characteristics and outcomes related to pediatric bone and joint infections caused by CA-S. aureus are very limited in India. In this tertiary hospital-based study, 74 patients with invasive S. aureus less than 18 years of age were identified between January 2004 and December 2008. All patients fulfilled the case definition of CA-S. aureus with evidence of infection before admission; they presented to our hospital without previous antibiotic use and were culture positive for S. aureus within 48 h of admission. All data including demographics, clinical features, treatment protocol, laboratory findings, and antimicrobial susceptibilities were recorded and compared using the SPSS 11.5 statistical software. Of the 74 patients with culture-positive S. aureus bone and joint infection, 41 had MRSA (55%). Forty-nine patients (66.2%) had osteomyelitis, of whom 29 (59.18%) had MRSA and 25 (33.7%) had septic arthritis, of whom 12 (48%) had MRSA. The MRSA group had a significantly higher erythrocyte sedimentation rate, C-reactive protein value, neutrophil count, and white blood cell count (P

The global epidemiology of HIV/AIDS is rapidly evolving in low and middle income countries. Women and adolescent females in Sub-Saharan Africa are at risk of HIV acquisition due to a myriad of complex biological, behavioral and structural factors. Primary HIV infection among women primarily drives the pediatric HIV epidemic. Postnatal transmission of HIV during breastfeeding is a major concern in LMIC, particularly in Sub-Saharan Africa where breastfeeding remains the only feasible, safe and culturally acceptable infant feeding choice. Given the remarkable discoveries in biomedical interventions to prevent sexual transmission of HIV and MTCT during breastfeeding, there is now a unique opportunity to rapidly implement combination HIV prevention packages, provide quality prevention of mother-to-child HIV transmission services, and improve maternal and infant survival. Although rapid scale-up of PMTCT interventions has occurred in Sub-Saharan Africa in the past five years, significant challenges remain towards reaching the ambitious goal of virtual elimination of new HIV infections among children on a global scale by 2015 and keeping their mothers alive. Rapid translation of scientific discoveries into policy and practice in conjunction with strong commitment from national leadership and global partners is crucial to end the pediatric AIDS and achieve a HIV-free generation.

Introduction. Gestational diabetes mellitus (GDM) is defined as carbohydrate intolerance of variable degree with onset or recognition during pregnancy. As prevalence of diabetes is linked to impaired glucose tolerance during antenatal period, routine antenatal screening of GDM is required. However, screening tests for GDM remain controversial.Objective. To review different diagnostic criteria for GDM.Materials and Methods. Freely accessible, full-text articles from 1964 to 2015, available in PubMed in English language, pertaining to screening of GDM were reviewed.Results. First diagnostic criteria for GDM in 1964 by O’Sullivan and Mahan, modified by the National Diabetes Data Group (NDDG) in 1979 and Carpenter in 1982. The cut-off value as per WHO definition of GDM was 140 mg/dL, 2 hours after 75 g glucose intake. Diabetes in Pregnancy Study Group India (DIPSI), in 2006, endorsed WHO criteria but irrespective of the last meal timings. Being cost-effective, it formed the basis of national guidelines for Indians in 2014.Conclusions. As typical clinical scenarios are usually varied, practical guidelines that meet the constraints of low-resource settings like India are required.

Cervical cancer is the most common cancer found in Indian women. Two human papillomavirus (HPV) vaccines were approved for use in India in 2006; however, neither has become readily accepted. Physician attitudes and recommendations are crucial in the uptake of HPV vaccines among adolescent women in the USA; thus, we ought to investigate provider attitudes and practices related to HPV vaccination in India via a survey administered to 210 Indian physicians. Of the 210 physicians, 46 % were community physicians and 54 % were academic physicians. The correct response to HPV knowledge questions was identified around 50 % of the time in 6/11 questions. Only 47 % of the physicians knew that there was an HPV vaccine approved for use in India. Only 11 % and 15 % of physicians strongly agree that the HPV vaccine will lead to long-lasting immunity and has a safe side effect profile, respectively. A total of 30 % of those surveyed reported that they would recommend the HPV vaccine to their patients, while 73 % agreed that the cost of the HPV vaccine is a major barrier to acceptance. After multivariate analysis, there were two significant variables independently associated with a physician's decision to recommend HPV vaccine. These variables were as follows: "whether the vaccine was freely available from the government sector" and "uncertainty about whether HPV must be persistent to cause cervical cancer vs not." Given the lack of knowledge among practicing physicians in Mangalore, increasing the education about HPV infection and HPV vaccination towards health care providers has the potential to increase vaccine recommendations.

(See the editorial commentary by Jain et al, on pages 707–709.) Background. Peramivir, an investigational intravenous neuraminidase inhibitor in Phase 3 trials for hospitalized patients, was made available during the 2009 H1N1 influenza pandemic under the Emergency Investigational New Drug (eIND) regulations. We describe the clinical characteristics and outcomes of all patients for whom peramivir was requested under the eIND. Methods. After obtaining eIND approval from the Food and Drug Administration and local institutional review board approval, clinicians caring for hospitalized patients with influenza administered intravenous peramivir and collected information on demographic characteristics, clinical characteristics, and outcomes. Results. From April through October 2009, peramivir was requested for 42 patients and administered to 20 adults and 11 children. At hospitalization, all patients had rapidly progressing, radiographically confirmed viral pneumonia with respiratory failure, and all but 1 patient required mechanical ventilation. In most patients, including 1 person with documented oseltamivir-resistant infection, the illness had progressed despite oseltamivir treatment. Peramivir was administered for 1–14 days (median duration, 10 days). The 14-day, 28-day, and 56-day survival rates were 76.7%, 66.7%, and 59.0%, respectively. Peramivir was generally well tolerated. Conclusions. Intravenous peramivir was well tolerated and was associated with recovery in most patients hospitalized with severe 2009 H1N1 influenza viral pneumonia and treated under an eIND.

Shetty AK, Ross GA, Pranikoff T, Gubareva LV, Sechrist C, Guirand DM, Abramson J, Lin J-J. Oseltamivir-resistant 2009 H1N1 influenza pneumonia during therapy in a renal transplant recipient. Abstract: The emergence of oseltamivir-resistant 2009 H1N1 influenza virus (conferred by the H275Y substitution in NA) during therapy or prophylaxis in immunocompromised patients is a serious concern. The optimal therapy for immunosuppressed patients with oseltamivir-resistant 2009 H1N1 influenza virus is unknown and few options exist. We report a 10-yr-old recipient of kidney transplant who was hospitalized with oseltamivir-resistant 2009 H1N1 influenza pneumonia complicated by severe respiratory failure, ARDS, and renal failure requiring institution of ECMO and CRRT. On presentation, treatment with oseltamivir (second course) and broad-spectrum antibiotics was initiated. Immunosuppressive agents were stopped on hospital day (d) 2. On hospital d 7, given his critical status, immunocompromised state, and difficulty in obtaining intravenous zanamivir, after obtaining ethical approval and parental consent, he was treated with intravenous peramivir (through an Emergency Investigational New Drug Application) for two wk. He tolerated the regimen well and his clinical status improved gradually. Several factors may have contributed to virus clearance and survival including recovery of the immune system, aggressive critical care support, and administration of peramivir. Ongoing surveillance is essential to monitor how oseltamivir-resistant H275Y mutant viruses may evolve in the future.

Background In China, chronic hepatitis B virus (HBV) infection is a major public health problem with ~6% of the population chronically infected. We investigated the effect of depression, anxiety, stigma, and disclosure on health-related quality of life (HRQoL) among people living with chronic HBV infection (CHB) in Dalian city, Liaoning, China. Methods Using a cross-sectional study design, 401 subjects with CHB were studied from January 2017 to September 2017. Study measures included Beck depression and anxiety inventory, WHOQOL-BREF, Toronto Chinese HBV Stigma Scale, and a questionnaire, which collected sociodemographic characteristic and disclosure of positive HIV status to sexual partners. The primary outcome was HRQoL score. A linear regression model examined the association between HRQoL and the potential risk factors including stigma, disclosure, depression, anxiety, and socio-demographic factors. Stigma, disclosure, depression, and anxiety are the covariates of interest. Age, sex, education, medical insurance, cirrhosis, other chronic diseases, and years of diagnose were adjusted in the model. Results Majority of participants were males (251, 62.59%). married (37.41%), and completed high and middle school (67%). Four factors of Depression, anxiety, stigma and disclosure had negative associated with QOL physical, psychological, social and environmental domains (P < 0.05) among CHB patients. Depression was the independent factor significant negative associated with HRQoL (P < 0.0001). Patients’ age had a significantly negative association with HRQOL in the psychological domain (P = 0.0083). Patients”education level had a significantly positive association with HRQOL for all four domains. Conclusion Our study is the first time to evaluate psychosocial factors affecting the HRQOL among people living with CHB in Dalian. Depression significantly affects the HRQOL among people living with CHB in Dalian, China warranting the urgent need for screening, early diagnosis, and implementation and integration of psychological interventions as part of routine care. Disclosures All authors: No reported disclosures.

The concentration of human immunodeficiency virus type 1 (HIV-1) is generally lower in breast milk than in blood. Mastitis, or inflammation of the breast, is associated with increased levels of milk HIV-1 and risk of mother-to-child transmission through breastfeeding. We hypothesized that mastitis facilitates the passage of HIV-1 from blood into milk or stimulates virus production within the breast. HIV-1 env sequences were generated from single amplicons obtained from breast milk and blood samples in a cross-sectional study. Viral compartmentalization was evaluated using several statistical methods, including the Slatkin and Maddison (SM) test. Mastitis was defined as an elevated milk sodium (Na + ) concentration. The association between milk Na + and the pairwise genetic distance between milk and blood viral sequences was modeled using linear regression. HIV-1 was compartmentalized within milk by SM testing in 6/17 (35%) specimens obtained from 9 women, but all phylogenetic clades included viral sequences from milk and blood samples. Monotypic sequences were more prevalent in milk samples than in blood samples (22% versus 13%; P = 0.012), which accounted for half of the compartmentalization observed. Mastitis was not associated with compartmentalization by SM testing ( P = 0.621), but Na + was correlated with greater genetic distance between milk and blood HIV-1 populations ( P = 0.041). In conclusion, local production of HIV-1 within the breast is suggested by compartmentalization of virus and a higher prevalence of monotypic viruses in milk specimens. However, phylogenetic trees demonstrate extensive mixing of viruses between milk and blood specimens. HIV-1 replication in breast milk appears to increase with inflammation, contributing to higher milk viral loads during mastitis.

1. Geeta Berera 2. Frank B. Magill 3. Melanie Oblender 1. Harbor-UCLA Medical Center, Torrance, CA 2. Peterborough, NH 3. The University of Texas Medical Branch at Galveston, TX This section of Pediatrics in Review reminds clinicians of those conditions that can present in a misleading fashion and require suspicion for early diagnosis. Emphasis has been placed on conditions in which early diagnosis is important and that the general pediatrician might be expected to encounter, at least once in a while. The reader is encouraged to write possible diagnoses for each case before turning to the discussion, which is on the following page. We invite readers to contribute case presentations and discussions. Case 1 Presentation The parents of a 6-year-old boy would like your opinion regarding a tonsillectomy and adenoidectomy for their son. His speech development has been delayed, and even now, despite 2 years of therapy, he is difficult to understand. The child had experienced recurrent ear infections for which pressure equalization tubes were placed 4 years ago. Physical examination reveals bilateral serous otitis media and a bifid uvula. The tonsils appear normal for his age. His speech has a hypernasal quality. An audiologic evaluation reveals bilateral conductive hearing loss. You see a pattern that suggests an underlying condition with important therapeutic implications. Case 2 Presentation A 6-week-old infant is brought to the emergency room because of bleeding from the umbilicus for 8 hours.

OBJECTIVE: To assess the impact of routine antenatal HIV testing for preventing mother-to-child transmission of HIV (PMTCT) in urban Zimbabwe. METHODS: Community counsellors were trained in routine HIV testing policy using a specific training module from June 2005 through November 2005. Key outcomes during the first 6 months of routine testing were compared with the prior 6-month "opt-in" period, and clients were interviewed. FINDINGS: Of the 4551 women presenting for antenatal care during the first 6 months of routine HIV testing, 4547 (99.9%) were tested for HIV compared with 3058 (65%) of 4700 women during the last 6 months of the opt-in testing (P < 0.001), with a corresponding increase in the numbers of HIV-infected women identified antenatally (926 compared with 513, P < 0.001). During routine testing, more HIV-infected women collected results compared to the opt-in testing (908 compared with 487, P < 0.001) resulting in a significant increase in deliveries by HIV-infected women (256 compared with 186, P = 0.001); more mother/infant pairs received antiretroviral prophylaxis (n = 256) compared to the opt-in testing (n = 185); and more mother/infant pairs followed up at clinics (105 compared with 49, P = 0.002). Women were satisfied with counselling services and most (89%) stated that offering routine testing is helpful. HIV-infected women reported low levels of spousal abuse and other adverse social consequences. CONCLUSION: Routine antenatal HIV testing should be implemented at all sites in Zimbabwe to maximize the public health impact of PMTCT.

Infection due to Chromobacterium violaceum is rare. Diagnosis may be delayed since Chromobacterium sepsis may mimic melioidosis, especially in melioidosis-endemic areas. Management of Chromobacterium infection is challenging given the propensity of this pathogen to cause visceral abscesses, drug resistance, and relapse. Mortality rates are high despite treatment. We report a case of C. violaceum septicemia in an immunocompetent adult from south India, who was successfully treated with combination antibiotic therapy. Physicians in tropical and subtropical regions must be aware of C. violaceum infection as it can mimic melioidosis.

A retrospective chart review was conducted to detect patients with sarcoidosis seen by pediatric rheumatology service from the period of 1992 to 2013 at Children's hospital of New Orleans. Twenty-seven patients were identified. The average duration of symptoms before diagnosis was 5 (range 1-120) months. Five patients had onset before the age of 5 years and were diagnosed with early-onset sarcoidosis. The most common manifestations at presentation were constitutional symptoms (62 %) followed by ocular (38 %). During the course of illness, 19/27 (70 %) had multiorgan involvement. Common manifestations included uveitis/iritis (77 %), fever (50 %), hilar adenopathy (42 %), arthritis (31 %), peripheral lympadenopathy (31 %), hepatosplenomegaly (31 %), parenchymal lung disease (27 %), and skin rash (19 %). Unusual manifestations included granulomatous bone marrow disease (3 cases), hypertension (2), abdominal aortic aneurysm (large vessel vasculitis; 1), granulomatous hepatitis (1), nephrocalcinosis (1), membranous nephropathy (1), refractory granulomatous interstitial nephritis with recurrence in transplanted kidney (1), CNS involvement (2), parotid gland enlargement (1), and sensorineural hearing loss (1). Biopsy specimen was obtained in 21/27 (77 %) patients, and demonstration of noncaseating granuloma associated with negative stains for mycobacteria and fungi was seen in 18 patients. Elevated angiotensin-converting enzyme level was seen in 74 % of patients. Treatment with oral prednisone was initiated in symptomatic patients with significant clinical improvement. Low-dose methotrexate (MTX) 10-15 mg/m(2)/week orally, as steroid-sparing agent, was administered in 14 patients. Other immunomodulators included cyclophosphamide (2 patients), etanercept (2), infliximab (2), mycophenolate mofetil (1), and tacrolimus (1). Childhood sarcoidosis is prevalent in Louisiana. Most of the affected children present with a multisystem disease associated with manifestations similar to those of adult patients. Low-dose MTX seems to be effective, steroid sparing, and safe adjunct to treat sarcoidosis with multiorgan involvement. Early-onset disease is less common and associated with increased morbidity, flares, and poor prognosis.

Malaria is caused by infection with 1 or more of 4 Plasmodium species Plasmodium falciparum Plasmodium malariae Plasmodium ovale and Plasmodium vivax which are transmitted to humans via the bites of female Anopheles mosquitoes. An estimated 200-500 million cases of malaria occur annually globally resulting in 1.5-2.7 million deaths 75% of which occur in children younger than 5 years of age in sub-Saharan Africa. In the U.S. most malaria cases are imported often by persons who travel to malaria-endemic countries without taking chemoprophylaxis (CP). This review focuses on malaria prevention for children who travel to or reside in malaria-endemic areas. (excerpt)

Summary Osteomyelitis and abscess of the clivus are rare conditions thought to arise from contiguous spread of infection from the paranasal sinuses [D.L. Hoistad, A.J. Duvall III. Sinusitis with contiguous abscess involvement of the clivus and petrous apices. Case report, Ann. Otol. Rhinol. Laryngol. 108 (1999) 463–466] or the temporal bone and petrous apex [S.A. Aziz, P.B. Fayad, F. Fulbright, M.L. Giroux, S.G. Waxman. Clivus and cervical spinal osteomyelitis with epidural abscess presenting with multiple cranial neuropathies, Clin. Neurol. Neurosurg. 97 (1995) 239–244], but have also been found to occur with no known source [R. Rusconi, S. Bergamaschi, A. Cazzabillan, V. Carnelli. Clivus osteomyelitis secondary to Enterococcus faecium infection in a 6-year-old girl, Int. J. Ped. Otorhinolaryng. 69 (2005) 1265–1268]. This report represents the second case of a clivus abscess in a child and demonstrates an innovative approach to surgical localization and treatment of abscesses in this area and also potentially in the nearby retropharyngeal region.

During the influenza A (H3N2) season of 2003–2004, several influenza-related complications and deaths were reported in children. Hemophagocytic lymphohistiocytosis complicating influenza A infection is very rare. We report a 3-year-old girl who presented with severe pneumonia and hemophagocytic lymphohistiocytosis associated with influenza A infection. Clinicians should be aware of hemophagocytic syndrome as a serious complication of influenza A infection.

The purpose of this pilot project was to assess the feasibility and acceptability of voluntary counselling and HIV testing (VCT) by pregnant women using community volunteers in Zimbabwe to prevent mother to child transmission (MTCT) of HIV. From July 1999 to June 2001, a short-course zidovudine (ZDV)-based perinatal HIV prevention programme was initiated in two antenatal clinics. Community volunteers, recruited from local community organizations, underwent a two-week training course in VCT, which included HIV/AIDS facts, systematic counselling approach, and practical counselling techniques using scripts and role-play. Rapid HIV testing was performed after informed consent. Lay counsellors conducted individual pre- and post-test counselling for HIV. A total of 35 women community volunteers were trained in VCT; 34 graduated and committed to work four hours per week in the clinic. Of the 6051 pregnant women presenting for antenatal clinics (ANC), 1824 (30%) underwent pre-test counselling and 1547 (26%) were tested, and 429 (28%) were HIV infected. Overall, 1283 (83%) returned for their test results including 406 (95%) of HIV-infected women. Of the 406 HIV-infected women who collected their test results, only 203 (50%) opted for ZDV prophylaxis to prevent MTCT of HIV. Over the two-year study period, two counsellors died and three sought employment at other organizations. Adherence to duty roster was 97% and no breach of confidentiality was reported. Despite many challenges, VCT delivered by community volunteers is feasible and acceptable for pregnant women aiming to reduce their risk of transmitting HIV to their infants. This programme is being implemented at several urban and rural MTCT sites in Zimbabwe and can serve as a model for other resource-poor countries.

Single-dose nevirapine reduces intrapartum human immunodeficiency virus 1 type (HIV-1) transmission but may also select for nonnucleoside reverse-transcriptase inhibitor (NNRTI) resistance in breast milk (BM) and plasma. Among 32 Zimbabwean women, median 8-week postpartum plasma and BM HIV-1 RNA levels were 4.57 and 2.13 log(10) copies/mL, respectively. BM samples from women with laboratory-diagnosed mastitis (defined as elevated BM Na(+) levels) were 5.4-fold more likely to have HIV-1 RNA levels above the median. BM RT sequences were not obtained for 12 women with BM HIV-1 RNA levels below the lower limit of detection of the assay used. In 20 paired BM and plasma samples, 65% of BM and 50% of plasma RT sequences had NNRTI-resistance mutations, with divergent mutation patterns.

Perinatal transmission of human immunodeficiency virus type 1 (HIV-1) is the primary cause of pediatric HIV infections. In recent years, perinatal HIV-1 transmission rates in the United States have declined markedly because of several factors that include enhanced voluntary counseling and HIV-1 testing (VCT) for pregnant women, widespread use of antiretroviral prophylaxis or combination antiretroviral therapy, avoidance of breastfeeding, and elective cesarean delivery. However, perinatal transmission of HIV-1 still occurs, and 300 to 400 infected infants are born annually, primarily because of missed prevention opportunities. The pediatrician plays a vital role in the prevention of perinatal transmission of HIV-1 by identifying newborns born to infected mothers who were not tested during pregnancy, administering antiretroviral prophylaxis, and ensuring follow-up to confirm or exclude the diagnosis of HIV-1 infection in early infancy. This article reviews recent advances in the prevention of perinatal transmission of HIV-1, discusses evaluation and treatment of infants exposed to HIV-1, and highlights certain unique features of HIV-1 infections in infants, with a focus on early diagnosis, clinical manifestations, treatment, and prognosis.